The Accreditation Association for Ambulatory Health Care (AAAHC) has released its 2025 Quality Roadmap, an annual report summarizing survey results from May 2024 through May 2025 across ambulatory surgery centers (ASCs), office-based surgery centers, primary care practices, and Medicare deemed status facilities. The findings are drawn directly from onsite accreditation surveys conducted under AAAHC's current standards (v43), which are set to be replaced on Dec. 16, 2025.
While most organizations achieve accreditation, the report underscores a familiar reality: infection prevention and control (IPC) remains one of the most challenging areas for compliance.
IPC in Surgical and Procedural Organizations
Nearly 90% of all surveys were conducted in ASCs and office-based surgery centers, where surveyors frequently cited IPC deficiencies. The three most common breakdowns were:
unsafe sterilization and high-level disinfection practices (IPC.170, cited in 13.3% of facilities);
inadequate program descriptions that failed to show how infections are prevented, identified, and managed (IPC.130, cited in 12.1%); and
lack of a governing body-approved written IPC program (IPC.100, cited in 9.3% of facilities).
These findings point to both governance and frontline practice gaps. Policies may exist on paper, but they often lack the oversight and follow-through required to ensure staff are consistently protecting patients from infection risks.
IPC in Primary Care Organizations
In primary care settings, IPC was the single-most cited area of noncompliance. Surveyors most often noted:
the absence of a formal, documented IPC program (IPC.100, cited in 15.2% of facilities);
programs that lacked sufficient detail on surveillance and prevention practices (IPC.130, cited in 14.7%);
and weaknesses in sterilization and disinfection processes (IPC.170, cited in 14.2%).
These results reflect a recurring challenge in outpatient clinics, where lean staffing and limited resources often leave infection control as an "add-on" responsibility rather than a fully supported program led by a qualified professional.
IPC and Immediate Jeopardy
According to the Quality Roadmap, infection control accounted for 22% of all immediate jeopardy (IJ) incidents over the past year. Many of these were tied to IPC.110 and IPC.170, where surveyors observed unsafe injection practices, failure to follow manufacturer instructions for cleaning scopes, reuse of disposable gowns, and cross-contamination caused by flawed workflows.
These lapses aren't minor. They represent immediate threats to patient safety and can jeopardize both accreditation and Medicare certification.
Why the Findings Matter: Infection Prevention and Control Standards in the Spotlight
Accreditation isn't just about passing a survey. It's about building systems that protect patients every day. IPC deficiencies persist because governing bodies often don't provide sufficient oversight, staff training isn't reinforced over time, and cultural gaps allow unsafe shortcuts. The 2025 Quality Roadmap makes clear that organizations must treat IPC not as a compliance checkbox but as a core component of safe, high-quality care.
IPC Compliance Readiness: Don't Risk Waiting
Infection prevention and control remains a key differentiator between organizations that excel during surveys and those that stumble — sometimes with serious consequences, including failed surveys, patient harm, and even the loss of insurance contracts or the ability to operate.
And with new AAAHC standards taking effect in December, the clock is already ticking. Organizations that wait until their next survey window to address IPC gaps may find themselves scrambling to catch up or worse, falling short when the stakes are highest.
If your last survey raised red flags in IPC, or if you're unsure whether your current program meets the latest expectations, now is the time to act.
Let's talk. Infection Control Consulting Services (ICCS) helps organizations get ahead of new standards, strengthen IPC policies and practices, and prepare staff to demonstrate compliance every day of the accreditation cycle. Don't wait until surveyors are at your door. Make sure your IPC program is airtight now.